The Blunt C/P Angle in trauma patients –BEWARE!

Traumatic diaphragmatic hernias-A common entity in hilly regions with a varied presentation

Dr Alok Vardhan Mathur, Dr Mohan Singh , Dr K. K. Sinha, Dr Madhukar Maletha, Dr J P Sharma, Dr Subhash Sharma,Dr Anurag Bijalwan

Shri Guru Ram Rai Insitute of Medical and Health Sciences, Patel Nagar,

Dehradun, Indiadralokvardhanmathur@yahoo.com

• (Figure55

• 35 year old male • Abdominal pain, vomiting, fever• On Examination- tachycardia, febrile, . Abdominal

tenderness, reduced air entry leftiu base• Inv – leucocytosis, Blunting of Lt C/P angle, Mild free fluid

in Abdomen • CT Abdomen-Diaphragmatic hernia with stomach and

bowel loops in chest• Laparotomy –Diverticulitis with abscess with purulent fluid

in peritoneal cavity- peritoneal lavage . Diaphragmatic hernia repaired in second stage

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Traumatic diaphragmatic injury - really an indicator of severe injury ?Dr Alok Vardhan Mathur, MS, Dr Manish Anand, DNB , Dr Madhukar Maletha, M Ch. (Ped Surg),

Prof (Brig) Ramesh Kumar, MS.Department of Surgery, Shri Guru Ram Rai Institute of Medical and Health Sciences,

Patel Nagar, Dehradun 248001

IntroductionBackground:  Traumatic diaphragmatic injuries occur as a result of both blunt and penetrating Trauma . Optimal treatment consists of repair through an abdominal approach with adequate attention to associated injuries. Most deaths in such patients are not the result of the diaphragmatic injury itself, instead they are often related to the associated injuries.

Discussion

• Look out for them, in the presence of haemo dynamic instability, with abdominal pain, intestinal obstruction, pneumo-pericarditis, tension feco-pneumothorax , even with hematemeisis and malena .

• More frequent in males with blunt high velocity trauma, and on the left side• X Ray signs: Collar sign, Diaphragmatic elevation, NG in thorax CT signs : Injury visualized, intra thoracic herniation , contrast extravasation ,

collar sign, intra thoracic displacement of liver and spleen with spleenic vein thrombosis, large right diaphragmatic rupture with herniation of liver, gall bladder, right kidney, ureter and renal vein

• FAST scan : Reduced diaphragmatic movement on same side• A high index of suspicion, together with the knowledge of the mechanism of

trauma, is the key factor for the correct diagnosis[2].• Incorrect interpretation of the x ray or only intermittent • hernial symptoms are frequent reasons for incorrect diagnosis[3]• Right sided ruptures - high mortality and morbidity ,less likely than left sided

tears • Mortality rates of 5 to 50% (higher when strangulation of herniating loops)• Meticulous per op examination of the diaphragm essential• Upto 30% present late [1] (Cause: delayed rupture of a devitalised diaphragmatic

muscle, often precipitated by extubation)

Conclusions: A careful search for these injuries is warranted in poly trauma patients, as up to 1.6% of these patients may have such injuries. They are commoner in males and on the left side. Their presentation may be silent or related to the cardio respiratory effects that they may cause. They should always be repaired to avoid long term complications resulting from strangulation of herniating bowel loops. Laparoscopy is  being used   increasingly to determine diaphragmatic integrity. Patients with isolated diaphragmatic injuries tend to recover without long-term disability

Methods

Case 1: A 35 year female, with high velocity RTA, poly trauma, head injury, lower limb fractures, pelvic fracture ,on ventilatory support, is referred to surgery, CXR and CT are shown below. On laparotomy, a 10 cm rent in diaphragm, with herniating viable stomach and bowel loops, is repaired, she makes an uneventful recovery - GCS score improves only gradually -Discharged from neurosurgery about 35 days later.

Case 2: 35 year old male - RTA victim – CXRPA shows blunt left CP Angle - ICD drains bilious fluid –Laparotomy reveals 5cm tear in left diaphragm with small bowel injury –diaphragm repaired with interrupted prolene sutures–post op develops intrabdominal collection-discharged on POD 16

Case 3: 12 year old boy – RTA victim with respiratory distress and shock- CXR shown , on laparotomy, viable stomach, spleen and small bowel found in chest – diaphragmatic rent is repaired with interrupted vicryl - discharged on POD 8.

Results: Three cases studied, Diaphragmatic hernias can occur in association with multiple trauma (Head injuries. limb and pelvic fractures, bowel perforation, iatrogenic trauma). They can be treated with good results. However the mortality and morbidity is often decided by the nature of associated injuries.

References

1. Pappas-Gogos G, Karfis E, Kakadellis J, Tsimoyiannis EC. Intrathoracic cancer of the splenic flexure. Hernia. 2007;11:257–259. doi: 10.1007/s10029-006-0182-3. [PubMed]

2. Mintz Y, Easter DW, Izhar U, Edden Y, Talamini MA, Rivkind AI. Minimally invasive procedures for diagnosis of traumatic right diaphragmatic tears: a method for correct diagnosis in selected patients. Am Surg. 2007;73:388–392. [PubMed

3. DeBlasio R, Maione P, Avallone U, Rossi M, Pigna F, Napolitano C. Late posttraumatic diaphragmatic hernia. A clinical case report. Minerva Chir. 1994;49:481–487. [PubMed]  

Results

Conclusions

• Blunt and penetrating trauma. • They are often associated with significant associated injuries• Recognized by fluid in the CP angle, lower lobe collapse, elevated

hemidiaphragm or by bowel loops in the chest. • Up to 70% of cases may be missed on chest radiographs and they may

be associated with significant associated injuries which may by themselves be fatal.

• CT scan and MRI may play and important role in diagnosis. • Stress the need of a high index of suspicion.• Optimal treatment consists of repair through an abdominal approach

with adequate attention to associated injuries.• Most deaths in such patients are not the result of the diaphragmatic

injury instead they are related to the associated injury.

Clinical presentationRespiratory distressDecrease breath sounds on affected sidePalpation of abdominal contents on insertion of chest tube or

drainage of bowel contents in ICDBowel sounds in chestParadoxical abdominal movement on respirationDiffuse abdominal pain Hemodynamic or respiratory instability Intestinal obstruction Asymptomatic Low oxygen saturation

Associated injuries

• Polytrauma – head injuries, limb and pelvic fractures.

• Bowel perforation• Spinal trauma• Other iatrogenic trauma• Asymptomatic

• Interval from trauma to repair- 12 hours to 10 years, one patients never underwent surgery

Findings

• Left sided in all patients• Small bowel, spleen, stomach, colon in chest• Strangulated small bowel in one patient• Head injury – cerebral contusions , spinal injury,

vertebral body fracture • Suspected the hernia on the basis of CXRPA in

all our patients , confirmation on basis of CT Scan

• Surgery offered to all , one refused it.

Results

• Twelve cases• Dehradun- tertiary care center• Frequent after RTA, fall from height in hilly regions• Sudden increase in intra-abdominal pressure following a

fall• Countre coup injuries- to explain spinal and head injuries• By themselves they can be treated with good results. • However the mortality and morbidity is often decided by

the nature of associated injuries. • More in males, in high velocity injuries, left side

Surgery

• All repaired abdominally• Mesh used in one• Results of repair were good• Three needed post op ventiatory support

• One pt- intraabdominal collection – treated conservatively

• Associated injuries influenced the morbidity hospital stay.

A careful search for these injuries is warranted in polytrauma patients, and upto 1.6% of such patients may have such injuries.

They are commoner in males On the left side(except in children where the rates are equal) Occur more frequently after blunt trauma especially after motor vehicle accidents. Their presentation may be silent or related to the cardiorespiratory effects that

they may cause. Some of them may be discovererd during laparotomy. They should always be repaired to avoid long term complications resulting from

strangulation of herniating bowel loops. Laparoscopy is being used increasingly to determine diaphragmatic integrity. The

outcome is generally related to concomitant injuries. Reported mortality ranges from 5.5-51%. People with isolated diaphragmatic injuries tend to recover without long-term

disability

Take home message

• Incidence in the foothills of the Himalayas may be higher than the plains- relation to climbing trees for animal fodder or falls from roads in hills onto trees or slopes

• Every blunting of CP Angle in trauma pts must raise the possibility

• Varied clinical spectrum.• Can be repaired by general surgeons themselves with

good results• Associated injuries often influence the eventual outcome