Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

Abstract

Introduction: Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.

Presentation of case: A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.

Discussion: We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.

Conclusion: A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.

Fig. 1

Anteroposterior erect chest radiograph on initial presentation showing only a small left-sided pleural effusion.

Fig. 2

Sagittal section of a CT chest, abdomen, and pelvis showing a small defect in the anterior part of the left hemidiaphragm.

Fig. 3

Ultrasound scan showing no obvious defect in the left hemidiaphragm.

Fig. 4

A further chest radiograph after discharge showing some pleural shadowing on the left when compared with the images on first admission (e.g. Fig. 1).

Fig. 5

CT with contrast showing a large defect in the left hemidiaphragm with herniation of omentum and the splenic flexure.