The Science Journal of the American Association for Respiratory Care
INTRODUCTION: Traumatic diaphragmatic rupture (TDR), although uncommon, is being diagnosed more frequently by health care professionals. Timely treatment is essential because of the high incidence of associated trauma and sequelae of delayed diagnosis such as incarcerated hernia. Thorough clinical evaluation, radiological investigations, computerized tomography (CT) and other diagnostic studies lead to a correct and timely diagnosis. A case involving a five-day delay in diagnosis with incarceration of left colon and spleen is presented. CASE SUMMARY: This case involves a 71-year-old male restrained driver involved in a motor vehicle crash. The patient was hypotensive at the scene. Upon arrival at this Level II trauma center, a chest radiograph was normal. A CT scan of the abdomen revealed multiple left-sided rib fractures and left lower lobe pleural fluid accumulation. A chest tube was placed prophylactically prior to surgery for reduction of an open left femur shaft and closed left radial fractures. Five days post-trauma, a repeat chest radiograph was suggestive of left diaphragmatic hernia. A repeat CT scan confirmed this diagnosis with herniation of the colon and spleen. The patient underwent successful surgical repair of the TDR. The post-operative period was uneventful. DISCUSSION: TDR occurs on the left side in 78% of all cases of diaphragmatic rupture. Two-thirds of the patients have an associated intra-abdominal trauma. Commonly associated thoracic injuries include rib fractures, hemothorax, pneumothorax, pulmonary contusion and flail chest. A chest radiograph depicting a bowel hernia through the defect is seen in 27-37% of the cases. The Initial chest radiograph may be normal in patients on mechanical ventilation with PEEP. Subsequently, when the PEEP is discontinued or the patient is extubated, a hernia may become manifest with a diagnostic chest radiograph. Rarely, a CT scan may reveal diaphragmatic defect as was the case in this patient. It is not uncommon to diagnose a left diaphragmatic hernia in a delayed phase, months to years after the initial trauma. Careful patient evaluation and thorough investigations are essential for early diagnosis and to prevent the complications of delayed treatment.