Teaching Case

Right-sided chest pain and dyspnoea after trauma

A 29-year-old male involved in a car accident presented with right-sided chest pain and dyspnoea. Systolic and diastolic blood pressures were 110/90 mmHg, cardiac pulse was 80/min. Physical examinations shown reduced breath sounds in the right hemi thorax. The posteroanterior (PA) chest radiograph revealed upper position of right hemi diaphragm. The multisection (MSCT) scan was preformed and the diagnosis was confirmed by multiplanar (MPR) coronal reformatted imaging, which revealed diaphragm rupture and intrathoracic displacement of the liver and also liver laceration. Laparotomy was performed and primer suture of diaphragm was done.

Diaphragmatic injuries occur in 0.8%–8% of patients after blunt trauma. Injuries to the left hemi diaphragm occur three times more frequently than injuries to the right side. There is also a high frequency of liver injuries, which are more frequently associated with right than with left diaphragmatic tears. Indeed, liver injuries are seen in 93% of patients with right diaphragmatic injuries. Although the diagnosis may be obvious at standard chest radiography or computed tomography (CT) in most situations, some specific signs require careful analysis with CT. Because of associated injuries (pelvic fractures, thoracic aortic injuries, central nervous system lesions, hepatic lesions), traumatic rupture of right diaphragm is overlooked in 30-50 % of cases with multiple injuries in initial presentation. Patients with a large traumatic diaphragmatic hernia may remain asymptomatic for a long time but suddenly occur with clinic presentation, so it is essential to undertake further procedures. In conclusion, if conventional radiographs show subtle signs of diaphragmatic injury in patients with multiple injuries after blunt trauma, we should undertake multisection CT as method of choice for imaging both thoracic and abdominal trauma and carefully look for diaphragmatic tear related with liver injury.