LATE POST-TRAUMATIC DIAPHRAGM RUPTURE IN A POLYTRAUMATIZED PATIENT: A CASE STUDY

Case History: 50 years old male with traumatic brain, chest and skeletal injuries after a car crash, transferred from a peripheral hos- pital to our ED. A Total Body CT-Scan was performed. After the positioning of a trans-skeletal traction of the left leg and 12 h of observation in our ED, he was admitted to the floor with the diagnosis of: ‘‘Head Trauma, Small Left Pneumothorax, Multiple costal frac- tures, Pulmonary Contusions, Pneumomediastinum, Sternal Fracture, Left Acetabulum Fracture’’. 19 days after the trauma the patient underwent a reduction and fixa- tion of the acetabulum fracture without complications. 23 days after the trauma suddenly occurred a change in the clinical condition of the patient. Clinical Findings: The patient appeared lethargic but aroused by oral stimulation, dyspnoeic, the hemodynamic was stable, no fever. At the clinical examination, the ventilation of the left hemithorax was remarkably reduced if compared to the contralateral; the patient reported pain to the palpation of the epigastrium and the bowel sounds were reduced. Investigation/Results: Firstly a Chest X-Ray was performed: it showed the presence of the gastric bubble in the left thoracic sec- tion. Afterwards a Chest and Abdomen CT-scan was performed. Diagnosis: Late post-traumatic rupture of the left diaphragm (lacer- ation of 8-10 cm) with thorax herniation of the upper 3/4th of the stomach and of the omentum, associated with a massive left pneu- mothorax with shift of the mediastinum. Therapy and Progressions: An emergency surgery for the reparation of the diaphragm rupture with a laparotomy approach was performed, followed by the positioning of a pleural drainage. Comments: Although unexpected it is necessary to consider a late diaphragmatic injury in a patient involved in a car crash where there is the possibility of a traumatic-related increase of the abdomen pressure.