Diaphragmatic injury in trauma: an entity that may be unnoticed

Abstract

Background: Traumatic diaphragmatic injuries are rare, but their incidence has escalated due to the increase in traffic accidents and cases of urban violence. This pathology can be unnoticed under many circumstances, so a high level of suspicion is required to establish an early diagnosis and to prevent life-threatening complications. Case presentation: A 43-year-old male patient who is found in public street presenting a generally poor condition, with stigmata of trauma in the right frontotemporal region, deformity in the right humerus, multiple excoriations caused by friction, presumed to have suffered a traffic accident. The thorax was found with no deformities, no bone crepitus, and no signs of breathing difficulty. Discusion and literature review: Based on the injury mechanism, diaphragmatic trauma can be classified as blunt and penetrating trauma, attributing approximately two-thirds of cases to penetrating trauma (gunshots, stab wounds) and one-third to blunt trauma (car accident). The injured diaphragm presents a solution of continuity whose healing does not occur spontaneously and in the course of its evolution, migration from the abdominal organs to the pleural cavity may occur. The initial study in patients with suspected diaphragmatic lesion is usually a chest X-ray with diagnostic sensitivity in left-sided lesions ranging from 27%-62%, and for right-sided lesions, it is 17%-33%. Suggestive findings of diaphragmatic lesion include the collar sign (compression of the herniated organ at the point of the diaphragmatic lesion), bowel loops within the chest, arcing shadows in the left hemithorax, and the presence of the gastric chamber in the chest. Computed tomography is the study of choice in the polytraumatized patient for the evaluation of abdominal and thoracic trauma, due to its high sensitivity and specificity in the diagnosis of associated lesions.