Imaging hemidiaphragmatic injury

An Unusual Presentation of Diaphragmatic Rupture

Representing less than 1% of all traumatic injuries, diaphragmatic injuries are uncommon and are usually associated with injuries in other thoracic and abdominal organs. We report a case of a diaphragmatic injury in a 38-year-old man who presented to the Emergency Department due to a pedestrian-vehicle accident. He had a massive hemothorax on the left due to a ruptured spleen. An exploratory laparotomy was done to manage the bleeding, restore the diaphragmatic hernia contents in their right anatomical position, conduct a splenectomy, and repair the diaphragmatic defect. Although the majority of diaphragmatic ruptures are diagnosed acutely, late presentations are usually reported in blunt trauma; therefore, a high clinical suspicion with imaging is essential for the diagnosis.

Traumatic diaphragmatic rupture: epidemiology, associated injuries, and outcome-an analysis based on the TraumaRegister DGU®

INTRODUCTION

Traumatic diaphragmatic rupture is a rare injury in the severely injured patient and is most commonly caused by blunt mechanisms. However, penetrating mechanisms can also dominate depending on regional and local factors. Traumatic diaphragmatic rupture is difficult to diagnose and can be missed by primary diagnostic procedures in the resuscitation room. Initially not life-threatening, diaphragmatic ruptures can cause severe sequelae in the patient's long-term course if untreated. The objective of this study was to assess the epidemiology, associated injuries, and outcome of traumatic diaphragmatic ruptures based on a multicenter registry-based analysis.

MATERIAL AND METHODS

Data from all patients enrolled in the TraumaRegister DGU® between 2009 and 2018 were retrospectively analyzed. That multicenter database collects data on prehospital, intra-hospital emergency, intensive care therapy, and discharge. Included were all patients with a Maximum Abbreviated Injury Scale (MAIS) score of 3 or above and patients with a MAIS score of 2 who died or were treated in the intensive care unit, for whom standard documentation forms had been completed and who had sustained a diaphragmatic rupture (AIS score of 3 or 4). The data has been analyzed using descriptive statistics and chi-square test or Mann-Whitney U test.

RESULTS

Of the 199,933 patients included in the study population, 687 patients (0.3%) had a diaphragmatic rupture. Of these, 71.9% were male. The mean patient age was 46.1 years. Blunt trauma accounted for 73.5% of the injuries. Primary diagnosis was established in the resuscitation room in 93.1% of the patients. Multislice helical computed tomography (MSCT) was performed in 82.7% of the cases. Rib fractures were detected in 60.7% of the patients with a diaphragmatic injury. Patients with diaphragmatic rupture had a higher mean Injury Severity Score (ISS) than patients without a diaphragmatic injury (32.9 vs. 18.6) and a higher mortality rate (13.2% vs. 9.0%).

CONCLUSIONS

In contrast to the literature, primary diagnostic procedures in the resuscitation room detected relevant diaphragmatic ruptures (AIS ≥ 3) in more than 90% of the patients in our study population. In addition, complex associated serial rib fractures are an important diagnostic indicator.

Blunt thoracic trauma: role of chest radiography and comparison with CT - findings and literature review

In the setting of acute trauma where identification of critical injuries is time-sensitive, a portable chest radiograph is broadly accepted as an initial diagnostic test for identifying benign and life-threatening pathologies and guiding further imaging and interventions. This article describes chest radiographic findings associated with various injuries resulting from blunt chest trauma and compares the efficacy of the chest radiograph in these settings with computed tomography (CT). Common chest radiographic findings in blunt thoracic injuries will be reviewed to improve radiologic identification, expedite management, and improve trauma morbidity and mortality. This article discusses demographic information, mechanism of specific injuries, common imaging findings, imaging pearls, and pitfalls and exhibits several classic imaging findings in blunt chest trauma. Thoracic structures commonly injured in blunt trauma that will be discussed in this article include vasculature structures (aortic trauma), the heart (cardiac contusion, pericardial effusion), the esophagus (esophageal perforation), pleural space and airways (pneumothorax, hemothorax, bronchial injury), lungs (pulmonary contusion), the diaphragm (diaphragmatic rupture), and the chest wall (flail chest). Chest radiography plays an important role in the initial evaluation of blunt chest trauma. While CT imaging has a higher sensitivity than chest radiography, it remains a valuable tool due to its ability to provide rapid diagnostic information in time-sensitive trauma situations and is ubiquitously available in the trauma bay. Familiarity with the gamut of injuries that may occur as well as identification of the associated chest radiograph findings can aid in timely diagnoses and prompt management in the setting of acute blunt chest trauma.

Imaging evaluation of diaphragmatic injuries: Improving interpretation accuracy

Diaphragmatic Injuries (DIs) remain a challenging diagnosis with potential catastrophic delayed complications. A high degree of suspicion in every case of severe blunt thoracoabdominal trauma or penetrating thoracoabdominal injury is essential. This review will present the evidence and controversies on this topic providing a practical tutorial for radiologists hoping to improve their interpretive accuracy for both blunt and penetrating DIs. The imaging signs of diaphragmatic injuries will be explained with emphasis on multidetector CT. Diagnostic pitfalls, available protocols and other issues will be presented.

Acute and chronic traumatic diaphragmatic hernia: 10 years' experience

Controversy persists regarding many aspects of traumatic diaphragmatic hernia (TDH). We aimed to understand why some traumatic diaphragmatic injuries present with chronic hernia and to evaluate diagnosis and treatment options. Fifty acute and 19 chronic TDH patients were diagnosed and treated at our institution over a 10-year period. Clinical data from these two groups were analyzed statistically and compared. Chronic TDH patients had a significantly lower Injury Severity Score than acute TDH patients (10.26 ± 2.68 vs. 26.92 ± 4.79, P < 0.001). The most common surgical approach for acute and chronic TDH was thoracotomy and laparotomy, respectively. The length of the diaphragmatic rupture was significantly shorter in chronic TDH patients than acute TDH patients (6.00 ± 1.94 cm vs. 10.71 ± 3.30 cm, P < 0.001). The mean length of hospital stay was significantly longer for acute TDH patients than chronic TDH patients (41.18 ± 31.02 days vs. 16.65 ± 9.61 days, P = 0.002). In conclusion, milder trauma and a smaller diaphragmatic rupture were associated with delayed diagnosis. A thoraco-abdominal computed tomography scan is needed for patients with periphrenic injuries to avoid delayed diagnosis of TDH. Improved awareness and understanding of diaphragmatic injuries will increase the rate of early diagnosis and improve prognosis.

Diagnostic significance of diaphragmatic height index in traumatic diaphragmatic rupture

Purpose

Traumatic diaphragmatic rupture resulting from blunt trauma is usually severe. However, it is often overlooked during initial evaluation because there are no characteristic signs and symptoms. Thus, this study aimed to determine the clinical characteristics of diaphragmatic rupture caused by blunt trauma and investigate the diagnostic usefulness of diaphragmatic height index (DHI) measured using chest radiographs.

Methods

The cohort comprised patients who were admitted due to diaphragmatic rupture from blunt trauma. Patients were divided into 2 groups; the control group comprised patients with blunt trauma who were matched for age, sex, and Injury Severity Score, while the DHI group comprised patients with diaphragmatic rupture from blunt trauma. Receiver operating characteristic curve was used to determine the cutoff value of DHI for diaphragmatic injury. The sensitivity, specificity, predictability, accuracy, and likelihood ratio of the cutoff were then determined.

Results

A total of 60 patients were confirmed to have diaphragmatic rupture. The mean DHI in patients with diaphragmatic rupture on the right and left side were both significantly different compared to that in the control group. A DHI cutoff value of >1.31 showed 71% sensitivity and 87% specificity for diagnosing right diaphragmatic rupture, while a cutoff value of <0.43 showed 87% sensitivity and 76% specificity for diagnosing left diaphragmatic rupture.

Conclusion

DHI can be useful in the diagnosis of diaphragmatic rupture. DHI as determined using chest radiographs in patients with blunt abdominal trauma, particularly in those ineligible for diagnostic work-up, may help in the diagnosis of diaphragmatic rupture.

Surgical management of chronic diaphragmatic hernias

Chronic diaphragmatic hernia (CDH) is an uncommon disease which may be associated with significant morbidity and mortality. Antecedent (even many months or years before CDH development) blunt or penetrating thoracic/thoraco-abdominal trauma is generally recognized. A wide spectrum of different mechanisms of injury, timing in presentation, size of the diaphragmatic defect, types and amount of abdominal viscera herniated into the chest cavity, clinical symptoms are observed in CDHs. Thoracic and abdominal CT scan (with coronal, axial and sagittal reconstructions) is the best diagnostic tool; sometimes thoracic MRI is needed to better define the extent of the diaphragmatic defect and the number of abdominal organs displaced into the chest cavity. Surgery (sometimes urgent) represents the treatment of choice for CDH; diaphragmatic hernia direct repair with a tension-free suture is generally attempted; in case of very large defects or when a tension-free suture is deemed unfeasible, the use of prosthesis is recommended. This review article will discuss about CDH aetiology, clinical presentation diagnosis and surgical treatment.

Imaging and Management of Thoracic Trauma

Thoracic injury results from penetrating and blunt trauma and is a major contributor to overall trauma morbidity and mortality in the United States. Modern imaging algorithms utilize ultrasound, chest radiograph, and computed tomography with intravenous contrast to accurately diagnose and effectively treat patients with acute thoracic trauma. This review focuses on the etiologies, signs and symptoms, imaging, and management of several life-threatening thoracic injuries including tracheobronchial rupture, pulmonary parenchymal injury, hemothorax, pneumothorax, diaphragmatic rupture, and axial skeleton injury.

Evaluation of the multi-slice computed tomography outcomes in diaphragmatic injuries related to penetrating and blunt trauma

PURPOSE

Traumatic diaphragmatic rupture is a diagnostic challenge for both surgeons and radiologists and generally occurs secondary to blunt and penetrating trauma of thoracoabdominal region.

MATERIAL AND METHODS

56 patients who underwent surgical procedure due to blunt or penetrating trauma were included to the study.

RESULTS

There were 37 diaphragmatic ruptures in the left side and 19 patients in the right side. The most common radiological finding was "the direct monitoring of defect" (54,3%).

CONCLUSION

Findings suggestive of diaphragmatic rupture must be carefully evaluated in patients with blunt or penetrating thoracoabdominal trauma.

Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: Difference between penetrating and blunt injuries

PURPOSE

Traumatic diaphragmatic rupture (TDR) needs early diagnosis and operation. However, the early diagnosis is usually difficult, especially in the patients without diaphragmatic hernia. The objective of this study was to explore the early diagnosis and treatment of TDR.

METHODS

Data of 256 patients with TDR treated in our department between 1994 and 2013 were analyzed retrospectively regarding to the diagnostic methods, percentage of preoperative judgment, incidence of diaphragmatic hernia, surgical procedures and outcome, etc. Two groups were set up according to the mechanism of injury (blunt or penetrating).

RESULTS

Of 256 patients with a mean age of 32.4 years (9-84), 218 were male. The average ISS was 26.9 (13-66); and shock rate was 62.9%. There were 104 blunt injuries and 152 penetrating injuries. Preoperatively diagnostic rate was 90.4% in blunt injuries and 80.3% in penetrating, respectively, P < 0.05. The incidence of diaphragmatic hernia was 94.2% in blunt and 15.1% in penetrating respectively, P < 0.005. Thoracotomy was performed in 62 cases, laparotomy in 153, thoracotomy plus laparotomy in 29, and combined thoraco-laparotomy in 12. Overall mortality rate was 12.5% with the average ISS of 41.8; and it was 21.2% in blunt injuries and 6.6% in penetrating, respectively, P < 0.005. The main causes of death were hemorrhage and sepsis.

CONCLUSIONS

Diagnosis of blunt TDR can be easily obtained by radiograph or helical CT scan signs of diaphragmatic hernia. For penetrating TDR without hernia, "offside sign" is helpful as initial assessment. CT scan with coronal/sagittal reconstruction is an accurate technique for diagnosis. All TDR require operation. Penetrating injury has a relatively better prognosis.

Traumatic diaphragmatic injuries: a retrospective review of a 12-year experience at a tertiary trauma centre

INTRODUCTION

Traumatic diaphragmatic injuries (TDIs) are clinically challenging. We aimed to review TDIs treated at a tertiary trauma centre over a 12-year period.

METHODS

This was a single-centre retrospective review of adult patients with TDIs treated between 1 January 2003 and 31 December 2014. Primary outcomes were mortality rates and Injury Severity Scores (ISS) associated with each TDI subtype. Secondary outcomes included proportions of TDIs diagnosed radiologically, operatively or during autopsy. We compared the TDI subtypes with respect to mechanism of injury, mortality rates and median ISS. Data was analysed using descriptive statistics.

RESULTS

Among 46 patients studied, the TDI subtypes noted were acute diaphragmatic herniation (n = 14, 30.4%), tears (n = 22, 47.8%) and contusions (n = 10, 21.7%). Patients with these TDI subtypes had a mortality rate of 35.7%-100%, while the ISS ranges for survivors and deaths were 22.0-34.0 (interquartile range [IQR] 6.5-23.0) and 53.5-66.0 (IQR 16.0-28.5), respectively. TDIs were identified via chest radiography (n = 2/33, 6.1%) and computed tomography (n = 6/13, 46.2%). All survivors (n = 21) and deaths (n = 25) underwent open surgery or autopsy, respectively, which confirmed TDIs. Blunt traumas and penetrating traumas were more frequently associated with acute herniation/contusions and tears, respectively. There were statistically significant differences among the TDI subtypes in their mechanism of injury, mortality rate and median ISS of survivors.

CONCLUSION

TDIs showed varying injury patterns with blunt versus penetrating mechanisms of injury, and were associated with significant mortality rates. Preoperative imaging had limited diagnostic use.

The Role of Computed Tomography in the Diagnostics of Diaphragmatic Injury After Blunt Thoraco-Abdominal Trauma

Background

Diaphragmatic injuries occur in 0.8–8% of patients with blunt trauma. The clinical diagnosis of diaphragmatic rupture is difficult and may be overshadowed by associated injuries.

Diaphragmatic rupture does not resolve spontaneously and may cause life-threatening complications.

The aim of this study was to present radiological findings in patients with diaphragmatic injury.

Material/Methods

The analysis of computed tomography examinations performed between 2007 and 2012 revealed 200 patients after blunt thoraco-abdominal trauma. Diaphragmatic rupture was diagnosed in 13 patients. Twelve of these patients had suffered traumatic injuries and underwent a surgical procedure that confirmed the rupture of the diaphragm. Most of diaphragmatic ruptures were left-sided (10) while only 2 of them were right-sided. In addition to those 12 patients there, another patient was admitted to the emergency department with left-sided abdominal and chest pain. That patient had undergone a blunt thoracoabdominal trauma 5 years earlier and complained of recurring pain. During surgery there was only partial relaxation of the diaphragm, without rupture.

The most important signs of the diaphragmatic rupture in computed tomography include: segmental discontinuity of the diaphragm with herniation through the rupture, dependent viscera sign, collar sign and other signs (sinus cut-off sign, hump sign, band sign).

Results

In our study blunt diaphragmatic rupture occurred in 6% of cases as confirmed intraoperatively.

In all patients, coronal and sagittal reformatted images showed herniation through the diaphragmatic rupture. In left-sided ruptures, herniation was accompanied by segmental discontinuity of the diaphragm and collar sign. In right-sided ruptures, predominance of hump sign and band sign was observed.

Other signs were less common.

Conclusions

The knowledge of the CT findings suggesting diaphragmatic rupture improves the detection of injuries in thoraco-abdominal trauma patients.

Blunt diaphragmatic lesions: Imaging findings and pitfalls

Blunt diaphragmatic lesions (BDL) are uncommon in trauma patients, but they should be promptly recognized as a delayed diagnosis increases morbidity and mortality. It is well known that BDL are often overlooked at initial imaging, mainly because of distracting injuries to other organs. Sonography may directly depict BDL only in a minor number of cases. Chest X-ray has low sensitivity in detecting BDL and lesions can be reliably suspected only in case of intra-thoracic herniation of abdominal viscera. Thanks to its wide availability, time-effectiveness and spatial resolution, multi-detector computed tomography (CT) is the imaging modality of choice for diagnosing BDL; several direct and indirect CT signs are associated with BDL. Given its high tissue contrast resolution, magnetic resonance imaging can accurately depict BDL, but its use in an emergency setting is limited because of longer acquisition times and need for patient’s collaboration.

Diaphragmatic injuries: challenges in the diagnosis and management

Establishing the clinical diagnosis of diaphragmatic injuries (DI) can be challenging for the trauma surgeon, as it is often clinically occult. Accurate diagnosis is critical however as a missed DI may result in grave sequelae due to herniation and strangulation of displaced intra-abdominal organs. The etiology of DI includes the following mechanisms: blunt, penetrating, and iatrogenic. Vital information about the mechanism of injury should be obtained from the emergency medical personnel. Left-sided hemidiaphragmatic injuries are considerably more common than right-sided injuries. Patients with right-sided hemidiaphragm rupture have higher pre-hospital mortality resulting from the greater impacting force require to produce a right-sided DI, associated with significant vascular injury. The diagnosis of a DI by imaging studies presents a challenge, as evidenced by the large number of investigative procedures employed to establish the diagnosis. Minimally invasive technology in the form of laparoscopy and thoracoscopy is in the trauma surgeon's diagnostic and therapeutic armamentarium. The surgical care of DI can be classified according to the phase of clinical presentation, into injuries requiring management in their acute phase versus those in their chronic phase. The patient's survival depends on the severity of their associated injuries, but if DI is not diagnosed promptly a missed injury can be associated with a high morbidity and mortality.

Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre

Purpose

Traumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre.

Methods

We used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed.

Results

Of the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury.

Conclusions

The detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.

Imaging of thoracic trauma

The purpose of this article is to demonstrate the commonly encountered findings in all types of thoracic trauma. It is not intended to be a systematic review of the literature, but will discuss and illustrate the differing imaging techniques which are used to diagnose common traumatic injuries in the thorax. Interventional radiology-based therapeutic interventions will be demonstrated.

Incidence of delayed and missed diagnoses in whole-body multidetector CT in patients with multiple injuries after trauma

BACKGROUND

Whole-body CT (WBCT) is the imaging modality of choice during the initial diagnostic work-up of multiple injured patients in order to identify serious injuries and initiate adequate treatment immediately. However, delayed diagnosed or even missed injuries have been reported frequently ranging from 1.3% to 47%.

PURPOSE

To highlight commonly missed lesions in WBCT of patients with multiple injuries.

MATERIAL AND METHODS

A total of 375 patients (age 42.8 ± 17.9 years, ISS 26.6 ± 17.0) with a WBCT (head to symphysis) were included. The final CT report was compared with clinical and operation reports. Discrepant findings were recorded and grouped as relevant and non-relevant to further treatment. In both groups, an experienced trauma radiologist read the CT images retrospectively, whether these lesions were missed or truly not detectable.

RESULTS

In 336 patients (89.6%), all injuries in the regions examined were diagnosed correctly in the final reports of the initial CT. Forty-eight patients (12.8%) had injuries in regions of the body that were not included in the CT. Fourteen patients (3.7%) had injuries that did not require further treatment. Twenty-five patients (6.7%) had injuries that required further treatment. With secondary interpretation, 85.4% of all missed lesions could be diagnosed in retrospect from the primary CT data-set. Small pancreatic and bowel contusions were identified as truly non-detectable.

CONCLUSION

In multiple traumas, only a few missed injuries in initial WBCT reading are clinically relevant. However, as the vast majority of these injuries are detectable, the radiologist has to be alert for commonly missed findings to avoid a delayed diagnosis.

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

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.

CT of blunt diaphragmatic rupture

The diagnosis of blunt diaphragmatic rupture (BDR) is difficult and often missed, leaving many patients with this traumatic injury at risk for life-threatening complications. The potential diagnostic pitfalls are numerous and include anatomic variants and congenital and acquired abnormalities. Chest radiography, despite its known limitations, may still be helpful in the early assessment of severe thoracoabdominal trauma and for detecting initially overlooked BDR or late complications of BDR. However, since the development of helical and multidetector scanners, computed tomography (CT) has become the reference standard; thus, knowledge of the CT signs suggestive of BDR is important for recognition of this injury pattern. A large number of CT signs of BDR have been described elsewhere, many of them individually, but the use of various appellations for the same sign can make previously published reports confusing. The systematic description and classification of CT signs provided in this article may help clarify matters and provide clues for diagnosing BDR. The authors describe 19 distinct CT signs grouped in three categories: direct signs of rupture, indirect signs that are consequences of rupture, and signs that are of uncertain origin. Since no single CT sign can be considered a marker leading to a correct diagnosis in every case of BDR, accurate diagnosis depends on the analysis of all signs present.

Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging

Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the 'gold standard' for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.

Incarcerated spontaneous transdiaphragmatic intercostal hernia

INTRODUCTION

Prolapse of abdominal viscera into the thoracic subcutis through the chest wall is known as transdiaphragmatic intercostal hernia (TIH). Herein, we present the first case of spontaneous TIH presenting as a thoracoabdominal emergency.

PRESENTATION OF CASE

A 78-year-old male presented with acute left thoracoabdominal pain following a sudden bulge at the left posterolateral chest wall corresponding to a partially reducible soft tissue mass with ecchymosis at the overlying skin. Paroxysmal cough during the last four days was also reported along with a prolonged daily application of a special tight abdominal belt that used while milking sheep. CT-scan of the abdomen showed intrathoracic proptosis of the splenic flexure through a defect of the left hemidiaphragm and subcutaneous prolapse of the herniated colon through the 7th intercostal space. On laparotomy, the herniated colon showed signs of ischemic necrosis leading to segmental colectomy followed by repair of the diaphragmatic defect.

DISCUSSION

The clinical diagnosis of spontaneous TIH demands very high index of suspicion and thorough patient's history. In this case the daily elevation of the intraabdominal pressure due to an abdominal milking belt might have caused gradual slimming and loosening of the diaphragm and the intercostals muscles rendering them vulnerable to sudden increases of the thoracoabdominal pressure due to violent coughing. Such a hypothesis is reasonable in the absence of traumatic injury in this patient.

CONCLUSION

Spontaneous TIH should be suspected in patients presenting with a sudden palpable chest wall bulge and associated thoracoabdominal symptoms in the absence of preceding injury.

Treating traumatic injuries of the diaphragm

Traumatic diaphragmatic injury (DI) is a unique clinical entity that is usually occult and can easily be missed. Their delayed presentation can be due to the delayed rupture of the diaphragm or delayed detection of diaphragmatic rupture, making the accurate diagnosis of DI challenging to the trauma surgeons. An emergency laparotomy and thorough exploration followed by the repair of the defect is the gold standard for the management of these cases. We report a case of blunt DI in an elderly gentleman and present a comprehensive overview for the management of traumatic injuries of the diaphragm.

CT imaging of blunt chest trauma

BACKGROUND: Thoracic injury overall is the third most common cause of trauma following injury to the head and extremities. Thoracic trauma has a high morbidity and mortality, accounting for approximately 25% of trauma-related deaths, second only to head trauma. More than 70% of cases of blunt thoracic trauma are due to motor vehicle collisions, with the remainder caused by falls or blows from blunt objects. METHODS: The mechanisms of injury, spectrum of abnormalities and radiological findings encountered in blunt thoracic trauma are categorised into injuries of the pleural space (pneumothorax, hemothorax), the lungs (pulmonary contusion, laceration and herniation), the airways (tracheobronchial lacerations, Macklin effect), the oesophagus, the heart, the aorta, the diaphragm and the chest wall (rib, scapular, sternal fractures and sternoclavicular dislocations). The possible coexistence of multiple types of injury in a single patient is stressed, and therefore systematic exclusion after thorough investigation of all types of injury is warranted. RESULTS: The superiority of CT over chest radiography in diagnosing chest trauma is well documented. Moreover, with the advent of MDCT the imaging time for trauma patients has been significantly reduced to several seconds, allowing more time for appropriate post-diagnosis care. CONCLUSION: High-quality multiplanar and volumetric reformatted CT images greatly improve the detection of injuries and enhance the understanding of mechanisms of trauma-related abnormalities.

The diaphragm

This article discusses the diaphragm from a surgical perspective. Although it is a relatively simple organ compared with other structures, the diaphragm serves important anatomic and functional roles necessary for proper respiratory function. It is an organ of little irregularity or disease, and easily manipulated in the operating room by those who have a basic understanding of its anatomic details.

Spiral head CT in the evaluation of acute intracranial pathology: a pictorial essay

The purpose of this pictorial essay is to review the benefits of spiral head computed tomography (CT) with routine multiplanar reformations in the evaluation of acute intracranial pathology. This technique is particularly useful in trauma patients for detection of skull base or calvarial fractures, thin tentorial subdural hematomas, or for more specific characterization of intracranial hemorrhage. The benefits of multiplanar reformations have been described for a variety of other diagnoses in the chest, abdomen, extremities, and spine, and their routine use continues to grow with the widespread availability of multi-slice CT scanners. In this article, we describe spiral head CT technique with multiplanar reformations as an alternative to the routinely used sequential technique. Subtle findings and lesions aligned predominantly in the axial plane can often be visualized to better advantage with multiplanar reformations. We also address technical factors for optimizing spiral technique.

[Delayed diagnosis of a diaphragmatic hernia in a patient on mechanical ventilation]

Traumatic rupture of the diaphragm is uncommon. Its early diagnosis is a challenge in diagnostic imaging. We present the case of a male multiple trauma patient in whom a left diaphragmatic hernia was discovered on weaning from mechanical ventilation 23 days after admission. We discuss the key imaging features of diaphragmatic rupture based on its physiopathology and thoracoabdominal pressure gradients. Very few cases of radiologically documented diaphragmatic hernias masked by mechanical ventilation have been reported.

Chronic traumatic diaphragmatic hernia

Chronic traumatic diaphragmatic hernia is an uncommon but persistent diagnosis associated with significant morbidity and mortality. Chronic TDH describes a spectrum of disease in antecedent mechanism of injury, timing of presentation, size of diaphragmatic defect, and amount and type of tissue displaced into the chest. Multiplanar CT with coronal, sagittal, and axial reconstruction is most effective in making this diagnosis. Once diagnosed, repair should be undertaken. Although transabdominal approaches may be successful, the authors prefer an open transthoracic approach, recognizing that either approach may need to incorporate access into the other body cavity to complete the repair. Basic hernia principles apply including the construction of a tension-free repair, which may necessitate the use of prosthetics. As surgeons become increasingly comfortable with minimally invasive techniques, more chronic TDH are likely to be approached in this fashion. Finally, as much of the morbidity and mortality is associated with the catastrophic consequences of chronic TDH, vigilance needs to be applied in an attempt to diagnose and then repair TDH while in the latent stage prior to the development of the catastrophic complications that herald the obstructive stage.

[Imaging of trauma with multi-detector computed tomography]

Diagnosis of trauma-related injuries is a key task in modern radiology. Early, thorough and accurate detection of potentially life-threatening injuries is crucial for fast and targeted initiation of treatment. Conventional radiography (CR) and ultrasound (US) are well-established and still represent the basic diagnostic tools for trauma imaging. However, a number of studies have shown a lower detection rate of injuries for radiography and ultrasound compared with computed tomography (CT). Multi-detector CT (MDCT) with its shorter scan time and increased accuracy has become the gold standard for many indications in trauma imaging. As MDCT has a higher radiation dose, its use should be restricted and carefully indicated especially when dealing with a younger patient population. Careful optimization of imaging parameters has to be performed to minimize exposure and maximize diagnostic safety. Modern MDCT examinations produce a large number of images, which have to be limited to a reasonable number for interpretation. This review article focuses on optimization of examination protocols and on how to handle the flood of images for viewing and archiving.

Multidetector CT of blunt thoracic trauma

Thoracic injuries are significant causes of morbidity and mortality in trauma patients. These injuries account for approximately 25% of trauma-related deaths in the United States, second only to head injuries. Radiologic imaging plays an important role in the diagnosis and management of blunt chest trauma. In addition to conventional radiography, multidetector computed tomography (CT) is increasingly being used, since it can quickly and accurately help diagnose a wide variety of injuries in trauma patients. Furthermore, multiplanar and volumetric reformatted CT images provide improved visualization of injuries, increased understanding of trauma-related diseases, and enhanced communication between the radiologist and the referring clinician.

Disruption of the Costal Margin with Transdiaphragmatic Abdominal Herniation Induced by Coughing

We present a case of disruption of the cartilage of the costal margin resulting in herniation of abdominal contents across the diaphragm into the chest and across a gap between the ribs into the subcutaneous tissues. The literature on this condition and its management is reviewed.