European Journal of Radiology, 10 (1990) 59-61 Elsevier
EURRAD
59
000 17
Pneumothorax due to delayed rupture of traumatic trans-diaphragmatic hernia 0. Landau, A. Schachner,
M.A. Lerner, E. Hauptman,
M. Friedman
gastric
and M.J. Levy
Department of CardiothoracicSurgery, Beilinson Medical Center, Petah Tikva, Israel (Received
15 June 1989; revised version received 5 October
Key words: Chest, pneumothorax;
Introduction Senertus in 1541 was the first to describe traumatic diaphragmatic rupture with herniated stomach in a man who died 7 months after a stab wound injury [ 11. In previous centuries, penetrating trauma was the major cause of traumatic rupture of the diaphragm, but in the 20th century, with the increasing number of motor vehicle accidents, blunt abdominal and thoracic trauma is the major cause of laceration of the diaphragm. Compound injury to the abdominal organs (spleen,
for reprints:
0720-048X/90/$03.50
0. Landau, M.D., Department
15 October
1989)
Gastric hernia, complication
liver, mesentery, bowel, etc.), the ribs, small pelvis and extremities may dominate the clinical picture, leading to a delay in the diagnosis of diaphragmatic hernia. Case report A 55-year-old man, involved in a motor vehicle accident, was brought to the emergency room complaining of left chest pain and mild headache. On physical examination there were no signs of respiratory distress. His blood pressure was 130/70, pulse rate was
Fig. 1. Chest roentgenogram on arrival. Subcutaneous emphysema, fracture of the third to the ninth rib and of the left clavicle.
Address
1989; accepted
Fig. 2. Pneumothorax
due to gastric perforation.
of Surgery B, Beilinson Medical Center, 49 100 Petah Tikva, Israel.
0 1990 Elsevier Science Publishers
B.V. (Biomedical
Division)
60
80 and respiratory rate was 18/min. He had tenderness of the left side of the chest, subcutaneous emphysema could be felt, and breath sounds were reduced over the left lung. No signs of neurological deficit, or abdominal irritation were noted. Blood examination showed marked leukocytosis of 22 OOO/ml,and slightly elevated lactic dehydrogenase 395. An AP chest roentgenogram (Fig. 1) showed subcutaneous emphysema in the left neck and subscapular regions, fracture of the third to the 9th ribs on the left and fracture of the left clavicle. An intercostal chest tube was immediately inserted into the left 5th intercostal space in the anterior axillary line. Air and serotic fluid were drained from the interpleural space. Chest X-ray showed good expansion of the left lung, but a ring of opacity was revealed in the lower part of the left hemithorax. Immediate fluoroscopy with oral Gastrografm revealed apparent partial relaxation of the left diaphragm with high positioning of the stomach. Thirty-six hours after admission, reduced breathing sounds over the left lung were noticed. A chest roentgenogram revealed a large left pneumothorax with a shift of the mediastinum to the right with colon loops and an almost empty stomach above the diaphragm (Fig. 2). A thorax drain was inserted into the second intercostal space at the midclavicular line and 300 cc of gastric content were drained. Emergency surgery showed that the stomach, transverse colon and omentum were bulging into the left hemithorax through a large subcardial rent. The paraesophageal crura were completely disrupted, and a small (1.5 cm) laceration in the fundus of the stomach, which was responsible for the air leak, was found. Recovery was uneventful and the patient was discharged from hospital on the 14th day. Discussion The most common cause of traumatic diaphragmatic hernia (TDH) is blunt abdominal trauma due to motor vehicle accident [2-51. Other causes are penetrating wounds (gun shot and stab wounds) and falls from heights. In sporadic cases, as a result of subxiphoidal insertion of epicardial pacemaker, or spontaneous rupture have been reported as well [6,7]. The pathophysiological cause of traumatic rupture of the diaphragm, in blunt trauma [ 8-101, is the sudden change in pressures between the abdominal and the intrathoracic cavities which lead to enormous strain upon the diaphragm. The tear occurs in the area of minor resistance in the diaphragm, which is in the left hemidiaphragm, in up to 90% of cases [ 111. The left predominance is true for blunt trauma and stab wounds. The incidence of pene-
trating wounds of right and left hemidiaphragm for gunshot wounds, as might be expected is the same [ 121. TDH rarely occurs as single lesion [ 13,141. The common additional injuries are multiple rib fractures, pelvic fracture and intraabdominal involvement (mainly spleen, liver and kidneys). The need for an urgent diagnosis of TDH is widely discussed in the literature and a delay can cause an increase in morbidity and mortality [ 151. The most useful diagnostic procedure is the chest roentgenogram [ 14,161. Suggestive signs are an air bubble in the thorax with an elevated diaphragm. Occasionally an unusual course of nasogastric tube can establish the diagnosis [ 171. In our case there was a delay of 36 hours in diagnosis, because of the relatively benign clinical picture and because the position of the diaphragm led to the wrong interpretation of both the chest X-ray and fluoroscopy. The patient was thought to have relaxation of the diaphragm and high positioning of the stomach. The differential diagnosis of the roentgenographic findings is paralysis of the diaphragm and in rare cases intrathoracic cyst or pulmonary tumor [ 191. Once the diagnosis is established, an urgent operation is indicated. An abdominal approach is preferred, when the diagnosis is suspected soon after the accident [ 13-211. If the diagnosis is delayed, however, a left thoracotomy is preferred. References 1 Nylus LM, Harkins H., (eds.) Hernia, Philadelphia, PA: JB Lippincott Co, 1964; 568. 2 Lucid0 JL, Wall, CA. Rupture of the diaphragm due to blunt trauma. Arch Surg (Chicago) 1963; 86: 989-999. 3 Arendroup HC, Jensen BS. Traumatic rupture of the diaphragm. Surg Gynecol Obstet 1982; 154: 526-530. 4 Beauchamp G, Khalfallah A, Girard R, Dube S, Laurendean F, Legros G. Blunt diaphragmatic rupture. Am J Surg 1984; 148: 292-295. 5 Waldschmidt ML, Laws HL. Injuries of the diaphragm. J Trauma 1982; 20: 587-592. 6 Swartz D, Livingstone C, Tio F, Mack J, Kent Trinkle J, Grover FL. Intrapericardial diaphragmatic hernia after subxiphoid epicardial pacemaker insertion; case reports. J Thorac Cardiovast Surg 1984; 88: 633-635. I Salomon J, Feller N, Levy MJL. A case of spontaneous rupture of the diaphragm. J Thorac Cardiovasc Surg 1969; 58: 221-224. 8 Childress ME, Grimes OF. Immediate and remote sequelae in traumatic diaphragmatic hernia. Surg Gynecol Obstet 1961; 113: 573. 9 De la Rocha AG, Creel RJ, Mulligan GW, Bums CM. Diaphragmatic rupture due to blunt abdominal trauma. Surg Gynecol Obstet 1982; 154: 175-180. 10 Langley JR, Innes BJ. Traumatic nonpenetrating diaphragmatic hernia. Am Surg 1975; 41: 409-412. 11 Luiting MG, Den Otter G. Rupture of the diaphragm due to blunt trauma. Neth J Surg 1982; 34: 13-17.
61 12 Wise L, Conners J, Hwang YH, Anderson C. Traumatic injuries to the diaphragm. J Trauma 1973; 13: 946-950. 13 Ward RE, Flynn TC, Clark WP. Diaphragmatic disruption secondary to blunt abdominal trauma. J Trauma 1981; 21: 35-38. 14 Brown GL, Richardson JD. Traumatic diaphragmatic hernia; a continuing challenge. Ann Thorac Surg 1985; 39: 170-173. 15 Gourin A, Garzon AA. Diagnostic problems in traumatic diaphragmatic hernia. J Trauma 1974; 14: 20-31. 16 Strug B, Noon GP, Beall AC Jr. Traumatic diaphragmatic hernia. Ann Thorac Surg 1974; 17: 444-449. 17 Periman SJ, Rogers LF, Mintzer RA, Muller CF. Abnormal
18 19
20 21
course of nasogastric tube in traumatic diaphragmatic hernia rupture of left hemidiaphragm. AJR 1984: 142: 85-88. Efrom G, Hyde I. Non penetrating traumatic rupture of the diaphragm. Clin Radio1 1967; 18: 394-398. Heidberg E, Wolverson MK, Hurd RN, Jagannadharao B, Sandaran M. CT recognition of traumatic rupture of the diaphragm. AJR 1980; 135: 369-372. Payne JH, Jr, Yellin AE. Traumatic diaphragmatic hernia, Arch Surg 1982; 117: 18-24. Severi Matlila, Antero Jarvinen, Tapani Mathila, Penthi Ketonen. Traumatic diaphragmatic hernia. Acta Chir Stand 1977; 143: 313-318.
EURRAD
59
000 17
Pneumothorax due to delayed rupture of traumatic trans-diaphragmatic hernia 0. Landau, A. Schachner,
M.A. Lerner, E. Hauptman,
M. Friedman
gastric
and M.J. Levy
Department of CardiothoracicSurgery, Beilinson Medical Center, Petah Tikva, Israel (Received
15 June 1989; revised version received 5 October
Key words: Chest, pneumothorax;
Introduction Senertus in 1541 was the first to describe traumatic diaphragmatic rupture with herniated stomach in a man who died 7 months after a stab wound injury [ 11. In previous centuries, penetrating trauma was the major cause of traumatic rupture of the diaphragm, but in the 20th century, with the increasing number of motor vehicle accidents, blunt abdominal and thoracic trauma is the major cause of laceration of the diaphragm. Compound injury to the abdominal organs (spleen,
for reprints:
0720-048X/90/$03.50
0. Landau, M.D., Department
15 October
1989)
Gastric hernia, complication
liver, mesentery, bowel, etc.), the ribs, small pelvis and extremities may dominate the clinical picture, leading to a delay in the diagnosis of diaphragmatic hernia. Case report A 55-year-old man, involved in a motor vehicle accident, was brought to the emergency room complaining of left chest pain and mild headache. On physical examination there were no signs of respiratory distress. His blood pressure was 130/70, pulse rate was
Fig. 1. Chest roentgenogram on arrival. Subcutaneous emphysema, fracture of the third to the ninth rib and of the left clavicle.
Address
1989; accepted
Fig. 2. Pneumothorax
due to gastric perforation.
of Surgery B, Beilinson Medical Center, 49 100 Petah Tikva, Israel.
0 1990 Elsevier Science Publishers
B.V. (Biomedical
Division)
60
80 and respiratory rate was 18/min. He had tenderness of the left side of the chest, subcutaneous emphysema could be felt, and breath sounds were reduced over the left lung. No signs of neurological deficit, or abdominal irritation were noted. Blood examination showed marked leukocytosis of 22 OOO/ml,and slightly elevated lactic dehydrogenase 395. An AP chest roentgenogram (Fig. 1) showed subcutaneous emphysema in the left neck and subscapular regions, fracture of the third to the 9th ribs on the left and fracture of the left clavicle. An intercostal chest tube was immediately inserted into the left 5th intercostal space in the anterior axillary line. Air and serotic fluid were drained from the interpleural space. Chest X-ray showed good expansion of the left lung, but a ring of opacity was revealed in the lower part of the left hemithorax. Immediate fluoroscopy with oral Gastrografm revealed apparent partial relaxation of the left diaphragm with high positioning of the stomach. Thirty-six hours after admission, reduced breathing sounds over the left lung were noticed. A chest roentgenogram revealed a large left pneumothorax with a shift of the mediastinum to the right with colon loops and an almost empty stomach above the diaphragm (Fig. 2). A thorax drain was inserted into the second intercostal space at the midclavicular line and 300 cc of gastric content were drained. Emergency surgery showed that the stomach, transverse colon and omentum were bulging into the left hemithorax through a large subcardial rent. The paraesophageal crura were completely disrupted, and a small (1.5 cm) laceration in the fundus of the stomach, which was responsible for the air leak, was found. Recovery was uneventful and the patient was discharged from hospital on the 14th day. Discussion The most common cause of traumatic diaphragmatic hernia (TDH) is blunt abdominal trauma due to motor vehicle accident [2-51. Other causes are penetrating wounds (gun shot and stab wounds) and falls from heights. In sporadic cases, as a result of subxiphoidal insertion of epicardial pacemaker, or spontaneous rupture have been reported as well [6,7]. The pathophysiological cause of traumatic rupture of the diaphragm, in blunt trauma [ 8-101, is the sudden change in pressures between the abdominal and the intrathoracic cavities which lead to enormous strain upon the diaphragm. The tear occurs in the area of minor resistance in the diaphragm, which is in the left hemidiaphragm, in up to 90% of cases [ 111. The left predominance is true for blunt trauma and stab wounds. The incidence of pene-
trating wounds of right and left hemidiaphragm for gunshot wounds, as might be expected is the same [ 121. TDH rarely occurs as single lesion [ 13,141. The common additional injuries are multiple rib fractures, pelvic fracture and intraabdominal involvement (mainly spleen, liver and kidneys). The need for an urgent diagnosis of TDH is widely discussed in the literature and a delay can cause an increase in morbidity and mortality [ 151. The most useful diagnostic procedure is the chest roentgenogram [ 14,161. Suggestive signs are an air bubble in the thorax with an elevated diaphragm. Occasionally an unusual course of nasogastric tube can establish the diagnosis [ 171. In our case there was a delay of 36 hours in diagnosis, because of the relatively benign clinical picture and because the position of the diaphragm led to the wrong interpretation of both the chest X-ray and fluoroscopy. The patient was thought to have relaxation of the diaphragm and high positioning of the stomach. The differential diagnosis of the roentgenographic findings is paralysis of the diaphragm and in rare cases intrathoracic cyst or pulmonary tumor [ 191. Once the diagnosis is established, an urgent operation is indicated. An abdominal approach is preferred, when the diagnosis is suspected soon after the accident [ 13-211. If the diagnosis is delayed, however, a left thoracotomy is preferred. References 1 Nylus LM, Harkins H., (eds.) Hernia, Philadelphia, PA: JB Lippincott Co, 1964; 568. 2 Lucid0 JL, Wall, CA. Rupture of the diaphragm due to blunt trauma. Arch Surg (Chicago) 1963; 86: 989-999. 3 Arendroup HC, Jensen BS. Traumatic rupture of the diaphragm. Surg Gynecol Obstet 1982; 154: 526-530. 4 Beauchamp G, Khalfallah A, Girard R, Dube S, Laurendean F, Legros G. Blunt diaphragmatic rupture. Am J Surg 1984; 148: 292-295. 5 Waldschmidt ML, Laws HL. Injuries of the diaphragm. J Trauma 1982; 20: 587-592. 6 Swartz D, Livingstone C, Tio F, Mack J, Kent Trinkle J, Grover FL. Intrapericardial diaphragmatic hernia after subxiphoid epicardial pacemaker insertion; case reports. J Thorac Cardiovast Surg 1984; 88: 633-635. I Salomon J, Feller N, Levy MJL. A case of spontaneous rupture of the diaphragm. J Thorac Cardiovasc Surg 1969; 58: 221-224. 8 Childress ME, Grimes OF. Immediate and remote sequelae in traumatic diaphragmatic hernia. Surg Gynecol Obstet 1961; 113: 573. 9 De la Rocha AG, Creel RJ, Mulligan GW, Bums CM. Diaphragmatic rupture due to blunt abdominal trauma. Surg Gynecol Obstet 1982; 154: 175-180. 10 Langley JR, Innes BJ. Traumatic nonpenetrating diaphragmatic hernia. Am Surg 1975; 41: 409-412. 11 Luiting MG, Den Otter G. Rupture of the diaphragm due to blunt trauma. Neth J Surg 1982; 34: 13-17.
61 12 Wise L, Conners J, Hwang YH, Anderson C. Traumatic injuries to the diaphragm. J Trauma 1973; 13: 946-950. 13 Ward RE, Flynn TC, Clark WP. Diaphragmatic disruption secondary to blunt abdominal trauma. J Trauma 1981; 21: 35-38. 14 Brown GL, Richardson JD. Traumatic diaphragmatic hernia; a continuing challenge. Ann Thorac Surg 1985; 39: 170-173. 15 Gourin A, Garzon AA. Diagnostic problems in traumatic diaphragmatic hernia. J Trauma 1974; 14: 20-31. 16 Strug B, Noon GP, Beall AC Jr. Traumatic diaphragmatic hernia. Ann Thorac Surg 1974; 17: 444-449. 17 Periman SJ, Rogers LF, Mintzer RA, Muller CF. Abnormal
18 19
20 21
course of nasogastric tube in traumatic diaphragmatic hernia rupture of left hemidiaphragm. AJR 1984: 142: 85-88. Efrom G, Hyde I. Non penetrating traumatic rupture of the diaphragm. Clin Radio1 1967; 18: 394-398. Heidberg E, Wolverson MK, Hurd RN, Jagannadharao B, Sandaran M. CT recognition of traumatic rupture of the diaphragm. AJR 1980; 135: 369-372. Payne JH, Jr, Yellin AE. Traumatic diaphragmatic hernia, Arch Surg 1982; 117: 18-24. Severi Matlila, Antero Jarvinen, Tapani Mathila, Penthi Ketonen. Traumatic diaphragmatic hernia. Acta Chir Stand 1977; 143: 313-318.
