Presentation
MVC: car versus pole
Patient Data
Bilateral pneumocaths have been placed by paramedics. Multiple right sided rib fractures. Abnormal density in the left lower zone with the hemidiaphragm contour not able to be traced and the gas bubble appearing elevated above its normal position. Mild shift of the mediastinum to the right. These appearances are highly suspicious for diaphragmatic rupture.
CT confirms left diaphragm rupture with portions of stomach, large bowel and small bowel herniating into the chest. Positive mass effect from the herniated contents causes mediastinal shift to the right and near complete collapse of the left lower lobe. The distal transverse colon is narrow at entering the hernia, then becomes significantly dilated when it sits anteriorly and then becomes collapsed suggesting closed obstruction of this segment. A left intercostal catheter has been placed into the herniated peritoneal contents rather than the pleural space and abuts several bowel loops. It is difficult to know if any iatrogenic bowel injury has occurred.
Other findings include; trace hemothoraces, small residual right anterobasal pneumothorax, displaced right rib fractures with flail segment, left anterior rib fractures, right scapula fracture, multiple thoracic fractures (some old and some new), mesenteric hematoma suggesting possible bowel injury and right iliac wing fracture.
Case Discussion
This case emphasizes the importance of assessing the hemidiaphragms on trauma chest x-rays. If the diaphragm outline cannot be clearly traced then one must look carefully for signs of diaphragm rupture such as herniated viscus in the chest and positive mass effect, both of which could be seen in this man. An intercostal catheter was presumably inserted in this case because the trauma team incorrectly thought the dense left lower zone opacity was hemothorax. It is important to remember that while hemothorax does produce positive mass effect (mediastinal shift), it should not be localized to the lower zone and should instead produce a generalized increased density throughout the hemithorax of a supine patient.
Unable to process the form. Check for errors and try again.