Traumatic diaphragm rupture and abdominal wall hernia

Case contributed by Dr Craig Hacking

Presentation

MVA v pole. Seat belt sign.

Patient Data

Age: 90
Gender: Female

The left hemithorax is partially imaged. Multiple displaced rib fractures on the left.

There is loss of normal normal contour of the left hemidiaphragm with opacity projecting over the left lower zone. The left costophrenic recess is not imaged.

The right lung and pleural space is clear. The cardiomediastinal contour is within normal limits.

CT Angiogram Thorax

No evidence of a traumatic aortic injury.

Moderate left haemopneumothorax.

There is a large defect in the posterolateral aspect of the left hemidiaphragm, through which herniates a large volume of mesenteric fat containing multiple locules of free gas extending into the left hemithorax as well as into the left lateral lower thoracic and upper abdominal wall. The splenic flexure and multiple small bowel loops (jejunum) herniate through the diaphragmatic rupture and fractured 9th and 10th ribs into the left lateral lower thoracic and upper abdominal wall.

There is a non-displaced fracture of the manubrium, extending more to the left, with associated haematoma in the anterior mediastinum. No other mediastinal haematoma. 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 oesophageal injury is clearly seen.

Patchy airspace consolidation is seen in the posterior inferior left upper lobe/lingula and left lower lobe. There is right posterior atelectasis.

No pericardial or right-sided pleural effusion. No right-sided pneumothorax. No lymphadenopathy.

Significant soft tissue stranding in the lateral aspect of the right breast is most likely due to haematoma/contusion.

Multiple right-sided rib fractures: 2nd (buckle fracture), 3rd, 4th (buckle fracture), 5th-7th ribs.

Multiple left-sided rib fractures: 1st, 2nd, 3rd (buckle fracture), 6th-10th ribs. There is marked distraction of fracture fragments of the 9th and 10th ribs.

No scapular or clavicular fractures detected.

CT Abdomen and Pelvis

There is disruption of the wall of the left lateral lower chest and upper abdomen with herniation of both the large bowel in the region of the splenic flexure, as well as several loops of small bowel into the wide mouthed defect.

There is a large volume of free intraperitoneal gas. There appears to be a laceration with a small defect in the colon in the region of the splenic flexure. A small bowel injury here also cannot be excluded. There is a very small volume of free intra-abdominal fluid. Subcutaneous tissue emphysema is present in the left lateral abdominal wall.

Hypodensity in the anterior pole of the spleen is in keeping with a small laceration.

The left adrenal gland is mildly bulky and indistinct with subtle surrounding fat stranding which may represent a traumatic injury. The right adrenal gland has a normal appearance.

The liver, pancreas and gallbladder are unremarkable. The kidneys are normal in appearance apart from cortical scarring in the left midpole. Sigmoid diverticular disease noted. The inferior vena cava is collapsed indicating hypovolaemia. Hypodensity in the left rectus abdominis likely represents calcification. Subcutaneous tissue contusion is demonstrated in the lower anterior abdominal wall.

CT Thoracic Spine

Grade 1 (2 mm) anterolisthesis of C7 on T1. Alignment of the thoracic spine is otherwise intact. There is a non-displaced avulsion fracture of the left transverse process of T12.

CT Lumbar Spine

There is a compression fracture of the superior endplate of L3 associated with 40% loss of vertebral body height. Left L1 and L2 transverse process fractures. There is grade 1 (4 mm) anterolisthesis of L4 on L5.

Conclusion

  1. Traumatic left hemidiaphragm rupture and defect in the left lateral abdominal wall with herniation of mesenteric fat into the left hemithorax and small and large bowel into the left lateral thoracic and abdominal wall.
  2. Large volume of free intra-abdominal gas associated with probable laceration of the colon in the region of the splenic flexure. A small bowel injury here also cannot be excluded.
  3. Left haemopneumothorax.
  4. Small splenic laceration.
  5. Multiple bilateral rib fractures.
  6. Sternal fracture.
  7. L3 compression fracture. Left T12 transverse process and left L1-L2 transverse process fractures.

The endotracheal tube and nasogastric tubes are in satisfactory position.

Both lungs are clear.

There is no pneumothorax or haemothorax identified.

Multiple rib fractures have been plated.

PlayAdd to Share

Case information

rID: 35173
Case created: 25th Mar 2015
Last edited: 4th Feb 2016
Tag: trauma
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.