by Dr Noreen Norfaraheen Lee Abdullah MD (UKM), MMed Radiology (UKM), AM(Mal)

Answer to Case Of the Month 
Traumatic Diaphragmatic Rupture

Discussion of Findings

Chest Radiograph
The child was intubated and the tip of the ETT is located at T3 level. There was ill definition of the left hemidiaphragm. The left hemithorax was opaque. No air bronchogram was noted. Cardiomediastinal contours were normal and there was mediastinal shift to the right. There was a right pleural effusion. The stomach bubble was not seen in the left hypochondrium. No rib fractures. The features were suspicious of left diaphragmatic rupture. 

CT Brain
Left frontal intraparenchymal haemorrhage with associated left parasagittal subarachnoid haemorrhage. There was no midline shift. The ventricles were not dilated.

Thorax CT
The scanogram showed abdominal contents ie. the stomach and bowel in the left chest cavity. This was revealed by the axial scans whereby the tip of the nasogastric tube was located in the left hemithorax. The superior portion of the spleen was also seen in the left hemithorax. The left lower lobe and left upper lobe demonstrated segmental lung contusion. Fluid was seen in the right pleural cavity. The mediastinum was shifted to the contralateral side. 

Conclusion

1. Left frontal intraparenchymal cerebral haemorrhage. 

2. Traumatic rupture of left hemidiaphragm with herniation of stomach, bowel and spleen into the left thoracic cavity.

3. Left lower lobe, left segmental upper lobe lung contusion. Right pleural effusion -most likely a haemothorax.

It occurs after blunt or crushing injuries due to sudden deceleration in a motor vehicle accident. Sometimes it can occur secondary to penetrating injuries e.g. stab or gunshot wounds.

Chest pain, dyspnea, upper abdominal tenderness, rigidity and rebound tenderness are some of the common symptoms. Pleural effusions, lower lobe atelectasis, loss of the diaphragmatic contour, contralateral mediastinal shift and diaphragmatic hernia are some of the features of diaphragmatic rupture.

Tears at both hemidiaphragms occur with equal frequency. The left side is affected in this case. The central tendon is torn usually anteriorly and transversely. The plain chest radiograph can establish the diagnosis most of the time. Elevation of the hemidiaphragm is quite specific.

If the rupture is on the left, the diagnosis is readily confirmed by passing a nasogatric tube and the tip will be located in the left hemithorax. Giving contrast medium through the nasogastric tube and performing a fluoroscopic study will further confirm the diagnosis.

Tears of the right leave are associated with pleural effusion and can be identified by ultrasound. CT scan is also helpful as it demonstrates the intrathoracic herniation of abdominal contents.

Identification of the diaphragmatic tear is important because if unattended will predisposed the patient to hernia formation and strangulation.
 

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Last Updated:
Tuesday, 04 January 2005