Visual Diagnosis : Right-Side Diaphragm Injury

Visual Diagnosis : Right-Side Diaphragm Injury Resulting from Blunt Trauma
Rory Howard, MD; A. Alijani, MD; Imtiaz A. Munshi, MD, MBA, FACS

Case Report
A 35-year-old man was involved in a snowmobile crash. He was transported by pre-hospital personnel to our Level I Trauma Center. Upon arrival, the primary survey revealed an awake, alert, and oriented individual, who complained of difficulty breathing and right hip pain. The admission vitals were significant for a heart rate of 104 beats/min with a normal blood pressure, respiratory rate, oxygen saturation of 98%, and temperature of 36°C (97°F). On physical examination there were decreased right-sided breath sounds at the base, and he experienced tenderness to palpation over the right chest wall.

Abdominal examination elicited tenderness to palpation at the right upper and lower abdominal quadrants. The pelvis was stable. Radiographic evaluation included a chest X-ray study that revealed decreased right lung aeration and right basilar opacification (Figure 1). Initial interpretation of the chest film suggested a right-sided pneumothorax with pulmonary contusion and a slight right diaphragmatic elevation. A chest tube was inserted into the right pleural space. There was reportedly a rush of air and 40 mL bloody output. Further radiographic evaluation included computed tomography (CT) scans of the chest, abdomen, and pelvis with intravenous and oral contrast (Figure 2). The chest CT scan showed the liver to be intrathoracic, a chest tube over the diaphragm posteriorly, a right diaphragm rupture, compression of the right middle and lower lung lobes, and multiple right-sided rib fractures (Figure 3, Figure 4). The patient was taken urgently to the operating room for an exploratory laparotomy. He was found to have a large central tear in the right diaphragm (14 × 5 cm); the right hepatic lobe was located entirely within the chest and there was a small laceration of the dome of the liver. He had no other abdominal injuries. The liver was manually reduced into the peritoneal cavity, and the diaphragm closed primarily with a running non-absorbable suture. He spent 4 days in the intensive care unit post-operatively. He recovered uneventfully, and was discharged home 10 days after surgery.

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