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17

Case Report ::

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Traumatic Herniation: Diane

Rupture of the Diaphragm CT Diagnosis

G. Holland1’2

and Leslie

Controversy exists diagnosis of traumatic

regarding rupture

the usefulness of CT in the of the diaphragm [1-3]. No

of the left hemidiaphragm

on CT with

Case Report A 29-year-old

man sustained

left-sided tures,

basilar air-space

with no definite

a blow to the left side of the chest

disease

examination disclosed a chest radiograph showed

and multiple

left lateral rib frac-

pneumothorax.

A CT examination performed 4 hr after the accident showed a leftsided pneumothorax, bilateral pleural fluid collections, bibasilar atelectasis, and fractures of several lower left lateral ribs. Fat was present in the lower left hemithorax, immediately anterior to atelectatic lung (Fig. 1 A) and lateral to the left hemidiaphragm (Fig. 1 B). An abrupt discontinuity of the left hemidiaphragm was adjacent to the

rib fractures;

the two edges of the diaphragmatic

rent were clearly

outlined by adjacent fat (Fig. 1 C). Traumatic rupture of the left hemidiaphragm was diagnosed. Despite the patient’s stable clinical status, the CT findings led to laparotomy 26 hr after the injury. The surgeon found a large tear of the

posterolateral

stomach,

portion

omentum,

of

and spleen

the

left

hemidiaphragm.

had herniated

through

injuries revealed abdominal conrepaired without was unremarka-

ble.

Discussion

hemiation.

wall in a motor vehicle accident. Physical lower left-sided flail chest. A portable supine

matic rent. A search for additional intraabdominal only a hematoma of the gastrosplenic ligament. The tents were reduced, and the diaphragmatic rent was complication. The patient’s postoperative recovery

visceral

herniation [4, 5]. We describe a case in which a posttraumatic left-sided diaphragmatic rent was shown on CT in the absence of visceral

Visceral

E. Quint1

large studies concerning the accuracy of CT in this setting have been done, either in patients with or in those without visceral herniation. Two case reports in the literature show discontinuity

Without

Portions

the diaphrag-

of

Although chest radiography has a primary role in screening for diaphragmatic injury, it is often inconclusive [6]. Approximately 85% of patients with a ruptured hemidiaphragm have abnormal findings on chest radiographs, but only one third of

these

radiographs

show

pathognomonic

evidence

of a dia-

phragmatic tear, such as bowel loops or a nasogastnic tube in the chest [2]. Other abnormalities suggestive but not diagnostic of diaphragmatic injury include an indistinct or

elevated

hemidiaphragm,

fractures,

and pulmonary

of these

findings

agnosis

appears

motion

to the frequent

with fast scanning

artifact,

facilitate

In cross section, as a continuous,

tissue

density

matic

fat infeniorly.

pneumothorax,

rib

[2, 6]. The nonspecificity

initial

misdi-

tears.

CT scanners, little

the diaphragm. usually

contributes

of diaphragmatic

Current quently

hemothorax, contusion

outlined The

direct

visualization

of

the intact left hemidiaphragm curvilinear

by lung superiorly right

times and conse-

hemidiaphragm

structure

of soft-

and subdiaphragis usually

less

well visualized, because it blends inferiorly with the liver, unless intervening fat or fluid is present [5]. Disruption of a

January 15, 1991 ; accepted after revision February 14, 1991. Department of Radiology, Box 0030, University of Michigan Hospitals, 1500 E. Medical Center Drive, Ann Arbor, Ml 481 09-0030. Address reprint requests to L. E. Quint. 2 Present address: Oepartment of Radiology, Henry Ford Hospital, Oetroit, Ml 48202. Received 1

AJR 157:17-18,

July 1991 0361-803X/91/1571-0017

© American

Roentgen

Ray Society

HOLLAND

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18

AND

QUINT

AJR:157, July 1991

Fig. 1.-contrast-enhanced CT (10-mm-thick contiguous sections, 2.0-sec scanning time) of left hemidiaphragmatic rupture. A, Left rib fracture (arrow), air in left side of chest wall, and left-sided hemothorax (H) are visible. Fat (F) anterior to atelectatic lung (L) is consistent with herniated omentum. B, An intact portion of left hemidiaphragm (arrowheads) is visible, outlined on both sides by fatty tissue. C, Scan obtained farther caudad shows medial and lateral edges of left hemidiaphragmatic rent (arrowheads) immediately adjacent to a fractured rib (arrow).

hemidiaphragm

may appear

as an abrupt

discontinuity,

with

the edges of the tear outlined by fat and possibly by lung. In patients with suboptimal diaphragmatic visualization or equivocal findings of diaphragmatic rupture, thin sections (e.g., 35 mm) may be useful

for better

anatomic

definition.

The accuracy of CT in diagnosing diaphragmatic rupture is controversial. In a retrospective review of 33 cases of blunt diaphragmatic injury, Voeller et al. [2] found insensitive method of diagnosing diaphragmatic

CT to be an tears. How-

ever, only four patients were evaluated by CT, and the CT technique was not described or illustrated. In a study of 196 patients examined with CT for abdominal trauma, Kearney et al. [1] found CT to be 99% accurate for diagnosing diaphragmatic disruption; two of 196 patients had proved diaphragmatic

rupture

at laparotomy.

Presence

or absence

of visceral

herniation was not specified in either of these studies. Case reports by Heiberg et al. [5] and Demos et al. [4] show CT examples of abrupt discontinuity of the medial portion of the hemidiaphragm. Both cases had associated abdominal visceral herniation. In our patient, the CT study showed both the medial and the lateral margins of the diaphragmatic rent. Although a small amount of omental tissue had herniated through the tear, no visceral herniation was

seen during the CT examination. Visceral herniation probably was delayed, occurring during the 22-hr interval between the CT study and surgery. Abdominal CT scanning in acute trauma can occasionally show diaphragmatic disruption before visceral herniation, leading to early surgical intervention and averting the potentially life-threatening complications of an undiagnosed herniation.

REFERENCES

1 . Kearney diagnostic

PA, Vahey T, Bumey pentoneal lavage

1989;124:344-347 2. Voeller GA, Aeisser

JA,

Fabian

RE, Glazer G. Computed tomography in blunt abdominal trauma. Arch Tc,

Kudsk

K, Mangiante

EC. Blunt

and Surg dia-

phragm injuries. Am Surg 1990;56:28-31 3. Toombs BO, SandIer CM, Lester AG. Computed tomography of chest trauma. Radiology 1981;140:733-738 4. Oemos TC, Solomon C, Posniak HV, Flisak MJ. Computed tomography in traumatic defects of the diaphragm. Clin Imaging 1989;13:62-67 5. Heiberg E, Wolverson MK, Hurd RN, Jagannadharao B, Sundaram M. CT recognition of traumatic rupture of the diaphragm. AJR 1980; 135: 369-372

6. Morgan AS, Flancbaum L, Esposito T, Coc EF. Blunt injury to the diaphragm: an analysis of 44 patients. J Trauma 1986;26 :565-568