A very rare case of right-sided, traumatic diaphragmatic rupture

O. Ismail, F. Hauswirth, V. Schreiber, G. A. Melcher

Objective

Right-sided traumatic diaphragmatic rupture is a rare entity of injury and accurate diagnosis is easily missed upon initial presentation.

Methods

A 80-year-old man suffered a collapse and fell down on his right chest. Physical examination showed pain due to thoracic compression. Conventional radiographs of the chest taken in two planes studies showed multiple fractures of the lower ribs VII-IX on the right side. No other pathologically findings could be detected. 36 hours later the patient presented with diffuse abdominal pain with tenderness in the right upper abdomen and rising white blood cells as well as CRP. Emergency abdominal sonography was obtained and revealed gall stones, but no other specific pathologically findings. Due to proceeding pain another conventional radiograph of the chest taken (CT-scan was actually planned but malfunctioning) suggested a diaphragmatic rupture because of an intestinal loop and suggested air-fluid level visible in the right hemithorax (see radiographs). Indication for emergent operation was made.

Results

Intraoperative findings showed an incarcerated colon owing to a traumatic rupture of the right-sided diaphragm. The affected segment of the colon was resected with end-to-end anastomosis and the lesion oft the diaphragm was sutured directly. Postoperative course was unproblematic.

Conclusion

The rupture has probably been caused by (intraoperatively) palpable, fractured ribs. Though, right-sided, diaphragmatic rupture is a very rare event due to protection of the liver and caused mostly by elevated intrabdominal pressure. Diaphragmatic rupture in general is a frequently delayed confirmed diagnosis. However awareness of this injury can trigger right and early diagnosis with prompt treatment.